La. Admin. Code tit. 48 § I-2301

Current through Register Vol. 50, No. 4, April 20, 2024

Section I-2301 - Disclosure of Risks/Patient Consent

A. Pursuant to R.S. 40:1299.40E, the Louisiana Medical Disclosure Panel recommends use of the following general form, or use of a substantially similar form, for disclosure of risks and hazards related to medical care and surgical procedures.

PATIENT CONSENT TO MEDICAL TREATMENT OR SURGICAL PROCEDURE AND ACKNOWLEDGEMENT OF RECEIPT OF MEDICAL INFORMATION INFORMATION ABOUT THIS DOCUMENT READ CAREFULLY BEFORE SIGNING

TO THE PATIENT: You have been told that you should consider medical treatment/surgery. Louisiana law requires us to tell you (1) the nature of your condition, (2) the general nature of the medical treatment/surgery, (3) the risks of the proposed treatment/surgery, as defined by the Louisiana Medical Disclosure Panel or as determined by your doctor, and (4) reasonable therapeutic alternatives and material risks associated with such alternatives.

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved.

In keeping with the Louisiana law of informed consent, you are being asked to sign a confirmation that we have discussed all these matters. We have already discussed with you the common problems and risks. We wish to inform you as completely as possible. Please read the form carefully. Ask about anything you do not understand, and we will be pleased to explain it.

1. Patient Name

_____________________________________

2. Treatment/Procedure:

(a) Description, nature of the treatment/procedure:

______________________________________________________

(b) Purpose:

______________________________________________________

3. Patient Condition:

Patient's diagnosis, description of the nature of the condition or ailment for which the medical treatment, surgical procedure or other therapy described in Item Number 2 is indicated and recommended:

___________________________________________

4. Material Risks of Treatment Procedure:

(a) All medical or surgical treatment involves risks. Listed below are those risks associated with this procedure that we believe a reasonable person in your (the patient's) position would likely consider significant when deciding whether to have or forego the proposed therapy. Please ask your physician if you would like additional information regarding the nature or consequences of these risks, their likelihood of occurrence, or other associated risks that you might consider significant but may not be listed below.

[ ] See attachment for risks identified by the Louisiana Medical Disclosure Panel

[ ] See attachment for risks determined by your doctor

(b) Additional risks (if any) particular to the patient because of a complicating medical condition are:

____________________________________________________

_____________________________________________________

(c) Risks generally associated with any surgical treatment/procedure, including anesthesia are: death, brain damage, disfiguring scars, quadriplegia (paralysis from neck down), paraplegia (paralysis from waist down), the loss or loss of function of any organ or limb, infection, bleeding, and pain.

5.Reasonable therapeutic alternatives and the risks associated with such alternatives are:

___________________________________________________

ACKNOWLEDGMENT

AUTHORIZATION AND CONSENT

(a)No Guarantees: All information given me and, in particular, all estimates made as to the likelihood of occurrence of risks of this or alternate procedures or as to the prospects of success, are made in the best professional judgment of my physician. The possibility and nature of complications cannot always be accurately anticipated and, therefore, there is and can be no guarantee, either express or implied, as to the success or other results of the medical treatment or surgical procedure.

(b)Additional Information: Nothing has been said to me, no information has been given to me, and I have not relied upon any information that is inconsistent with the information set forth in this document.

(c)Particular Concerns: I have had an opportunity to disclose to and discuss with the physician providing such information, those risks or other potential consequences of the medical treatment or surgical procedure that are of particular concern to me.

(d)Questions: I have had an opportunity to ask, and I have asked, any questions I may have about the information in this document and any other questions I have about the proposed treatment or procedure, and all such questions were answered in a satisfactory manner.

(e)Authorized Physician: The physician (or physician group) authorized to administer or perform the medical treatment, surgical procedures or other therapy described in Item 2 is:

__________________________________

(Name of authorized physician or group)

(f) Physician Certification: I hereby certify that I have provided and explained the information set forth herein, including any attachment, and answered all questions of the patient, or the patient's representative, concerning the medical treatment or surgical procedure, to the best of my knowledge and ability.

_________________________________________________________

(Signature of Physician) Date Time

CONSENT

Consent : I hereby authorize and direct the designated authorized physician/group, together with associates and assistants of his choice, to administer or perform the medical treatment or surgical procedure described in item 2 of this Consent Form, including any additional procedures or services as they may deem necessary or reasonable, including the administration of any general or regional anesthetic agent, x-ray or other radiological services, laboratory services, and the disposal of any tissue removed during a diagnostic or surgical procedure, and I hereby consent thereto.

I have read and understand all information set forth in this document, including any attachment, and all blanks were filled in prior to my signing. This authorization for and consent to medical treatment or surgical procedure is and shall remain valid until revoked.

I acknowledge that I have had the opportunity to ask any questions about the contemplated medical procedure or surgical procedure described in Item 2 of this consent form, including risks and alternatives, and acknowledge that my questions have been answered to my satisfaction.

________________________________________________________

Witness

_________________________________________________________

Patient or Person Authorized to Consent Date/Time

___________________________________

Relationship

If consent is signed by someone other than the patient, state the reason:

_______________________________________________________

Attachment to Consent to Medical Treatment or Surgical Procedure and Acknowledgment of Receipt of Medical Information

_____________________________________________________

Patient's Signature Date/Time

La. Admin. Code tit. 48, § I-2301

Promulgated by the Department of Health and Hospitals, Medical Disclosure Panel, LR 18:1391 (December 1992), repromulgated LR:1581 (December 1993), amended LR 20:307 (March 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:1299, 40E et seq.